Terms of Care and Consent Form

Welcome to Heartland Christian Counseling! Please read the following document carefully, as it contains important information regarding the treatment you and/or your family will receive at Heartland Christian Counseling. After careful review, please sign your acknowledgement of our policies and procedures.

Confidentiality: The information you share with your health care professional is held in the strictest confidence and may not be released to anyone without your written consent, as prescribed by law. There are a few exceptions to this, which are also regulated by state law. For example, in cases of suspected child or elderly abuse, or if a person poses a serious and imminent danger to her/himself or to someone else, your health care professional is required by law to report this information to the proper authorities. Information subpoenaed by a valid court order is usually not protected by this limit on confidentiality. These situations rarely occur and are the only exceptions to otherwise 100% confidentiality of what you talk about during therapy. In addition, some insurance companies require very brief and limited treatment information including diagnosis, and in some cases, information about presenting symptoms and treatment planning. Upon signing consent to release information, you are encouraged to discuss the amount, type, and purpose of information to be released if you have any concerns in this area. Our policy is to allow you to maintain the highest possible level of confidentiality.

Fees/Billing: Each client (parent/ legal guardian for minors) is responsible for managing the finances of the therapy relationship. Your health insurance may cover all or part of the fees, and we will work with you to facilitate the exchange of information with your insurance company for payment, as well as directly submitting claims electronically to your insurance carrier. It is your responsibility to check with your insurance carrier to make sure that Heartland Christian Counseling is a participant in your insurance plan. If your insurance company requires a pre-authorization, please bring the authorization number with you at the time of your first visit. You should contact your health insurance company or consult with our office for additional information. If you choose not to access your medical insurance for payment, or do not have coverage, please note that each client is responsible for payment for services rendered the day of the appointment. Cash, check, and most major credit cards are acceptable payment methods.

Since we reserve your appointment time, there will be a $75 charge for any appointments missed without prior notification. Insurance does not cover the no-show fee, which means that it is essential for you to cancel your appointment at least 24 hours in advance to avoid this charge.

Phone calls and other contacts: The scheduling and canceling of appointments are handled

through the same phone number (though follow-up appointments will generally be set up at the end of the previous session If you need to reschedule your appointment, please leave a message on the office voicemail, and your call will be returned by the end of the next business day. You may also leave a message on the voicemail to cancel appointments within 24 hours of your scheduled time. Please include your name, the appointment time, and a contact phone

In the event of an emergency, we recommend you contact 911 or head to your nearest emergency department, whichever is most appropriate for the situation.

By signing this consent form, I agree to pay Heartland Christian Counseling for any co-insurance, co-payments, deductibles or other amount not paid for by insurance. Failure to do so my result in collection action or denial of future

I have read Heartland Christian Counseling's Terms of Care and agree to follow all policies and procedures as described above.